Imaging Technologies to Assist in Melanoma Detec3on Prac3cal Considera3ons for Pa3ents with Melanoma/Dysplas3c Nevi

Imaging Technologies to Assist in Melanoma Detec3on Prac3cal Considera3ons for Pa3ents with Melanoma/Dysplas3c Nevi Michael A. Marche@, MD Assistant ABending, Dermatology Service Memorial Sloan KeBering Cancer Center New York, NY Summer AAD Mee3ng 2017, NYC Saturday, July 29th, 9:40 AM

PHOTOGRAPHY & VIDEOTAPING ARE STRICTLY PROHIBITED IN ALL EDUCATIONAL SESSIONS CELL PHONES MUST BE PLACED ON VIBRATE OR TURNED OFF ViolaBons of this policy will result in removal from the session and possible revocabon of meebng registrabon. Session directors will be closely monitoring such occurrences. FOTOGRAFIA E FILMANDO SÃO ESTRITAMENTE PROIBIDOS EM TODAS AS SESSÕES EDUCACIONAIS TELEFONES CELULARES DEVEM SER COLOCADOS EM VIBRAR OU DESLIGADOS Violações desta políbca resultará na remoção de sessão e possível revogação do registo da reunião. Diretores de sessão irão acompanhar de perto tais ocorrências.

DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY Michael A. Marchetti, MD F023 Practical Considerations for Patients with Melanoma or Dysplastic Nevi DISCLOSURES IGNYTA: Consultant Honoraria

Objec3ves 1) Iden3fy goals of using imaging technologies to aid melanoma diagnosis 2) Describe prac3cal imaging technologies for melanoma detec3on a. Dermoscopy b. Total body photography c. Sequen3al digital dermoscopic imaging

Importance of earlier detec3on Although prognosis of melanoma <1mm is excellent, 27% of deaths in US are secondary to these cancers Balch CM, et al. JCO. 2009 Geller AC, et al. JAAD. 2011

Dermoscopy

Three meta-analyses show that dermoscopy improves diagnos3c accuracy for melanoma over naked-eye examina3on alone

Prac3cal Tips Use dermoscopy on all lesions in absence of TBP Only way to improve sensi3vity Apply clinical context Moles breed true Tape test Ink test Oblique Dermoscopy

Maumi Y, et al. Dermatology. 2009

Total body photography

Total body photography catalogues skin surface

Prac3cal Tips For efficiency can train nurse or other staff to perform side-by-side comparison and flag all concerning lesions MD can then evaluate flagged lesions Involve pa3ent SSE aided by TBP

TBP improves sensi3vity of SSEs in detec3ng new and changing moles 100 50 With TBP No TBP 0 Sensi3vity Specificity Oliveria et al. Arch Dermatol. 2004

Sequen3al digital dermoscopic imaging (SDDI)

Sequen3al dermoscopy imaging (SDI) involves repea3ng dermoscopy images* over 3me to detect change Baseline *Must examine side-by-side on monitor 3-months later

Short-term (3-4m) - Monitor suspicious melanocybc lesions without diagnosbc features for melanoma No change benign; nevus 3 months ~99.2% unchanged lesions are benign ANY Change biopsy; melanoma in situ 93-96% melanomas will change w/in 3m 16% benign nevi change w/in 3m 3 months

What are suspicious melanocybc lesions without diagnosbc features of melanoma???

0.0 100% sure benign <- Observe Biopsy -> 1.0 100% sure melanoma

0.0 100% sure benign <- Observe <- Benign Biopsy -> Malignant -> 1.0 100% sure melanoma

0.0 100% sure benign <- Observe <- Benign Biopsy -> Malignant -> 1.0 100% sure melanoma This is when I consider 3m STMM

0.0 100% sure benign <- Observe <- Benign Biopsy -> Malignant -> 1.0 100% sure melanoma Do not monitor these lesions!!

Long-term (>6m) Monitoring greater number of less suspicious nevi in pabents undergoing long-term screening No or non-significant change 95% of lesions Significant change 4-5% of lesions Melanoma-specific structures Focal changes Asymmetric changes

Long-term monitoring 1. Melanoma-specific structures 2. Focal changes - color, structure, size 3. Asymmetric change

Prac3cal Tips Never monitor raised or indurated lesions In case nodular or desmoplas3c melanoma Don t perform 3-4m monitoring of lesions with peripheral globular pabern or streaks Expected change Rarely melanomas may not change within 3-4 months Right pa3ent/lesion How to counsel pa3ents

Considera3ons Decrease Sensi3vity Missed melanomas No change N.B. Facial and non-facial lesions suspected to be possible lenbgo maligna melanoma should be monitored for greater than 3-months Altamura, Arch Dermatol. 2008

Right pa3ent Always give the pt op3on of biopsy today vs. short-term monitoring People who will be returning to see you Right lesion If you worry about the lesion when the pa3ent leaves, call pt back lecture test

I never completely dismiss a lesion as benign. I state that the lesion has no features of concern today but that if change is noted in the future, the pa3ent should return for prompt re-examina3on. Why? (a) early melanomas are difficult to iden3fy (b) sensi3vity is not 100% (c) melanomas can arise in associa3on with nevi (d) collision tumors are not infrequent (e) I have many pa3ents who tell me their dermatologist said their melanoma was nothing to worry about

Use of dermoscopy, SDI, TBP together is complementary and effecbve in monitoring those at high-risk for melanoma JAMA Dermatology. 2014 311 pabents, median f/u 3.5 years 75 melanomas detected (14 baseline) postbaseline median thickness was in situ 38% TBP; 39% SDI 5 > 1mm thickness (desmo/nodular types) NNB of 4.4 to 1 (melanocybc lesions)

Baseline TBSE (clinical and dermoscopy all lesions) SDDI Suspicious/Outlier Biopsy Melanoma Follow-up 1. TBP New, changing, outlier Dermoscopy Suspicious/Outlier Long-term SDDI Concerning change Biopsy Short SDDI Biopsy

Thanks